Contributors CQ had the idea for the article, contributed to the literature research, contributed to the study design, collected the data,
contributed to the data analysis and reviewed the drafts of the manuscripts. GM collaborated to collect and to manage data,
collaborated to data analysis, helped to conceptualise ideas and reviewed the drafts of the manuscripts. NN collaborated in
collection of the data and to the idea for the study, helped to conceptualise ideas and revised the drafts of the manuscript.
SB, MM and DS contributed to the analysis and drafted the article. All the authors have contributed to conception of the article,
drafting and revision of the content.

Accepted 26 June 2012

Published Online First 29 September 2012

Abstract

Background During the 1990s, Italy privatised a significant portion of its healthcare delivery. The authors compared the effectiveness
of private and public sector healthcare delivery in reducing avoidable mortality (deaths that should not occur in the presence
of effective medical care).

Methods The authors calculated the average rate of change in age-standardised avoidable mortality rates in 19 of Italy's regions
from 1993 to 2003. Multivariate regression models were used to analyse the relationship between rates of change in avoidable
mortality and levels of spending on public versus private healthcare delivery, controlling for potential demographic and economic
confounders.

Results Greater spending on public delivery of health services corresponded to faster reductions in avoidable mortality rates. Each
€100 additional public spending per capita on NHS delivery was independently associated with a 1.47% reduction in the rate
of avoidable mortality (p=0.003). In contrast, spending on private sector services had no statistically significant effect
on avoidable mortality rates (p=0.557). A higher percentage of spending on private sector delivery was associated with higher
rates of avoidable mortality (p=0.002). The authors found that neither public nor private sector delivery spending was significantly
associated with non-avoidable mortality rates, plausibly because non-avoidable mortality is insensitive to healthcare services.

Conclusion Public spending was significantly associated with reductions in avoidable mortality rates over time, while greater private
sector spending was not at the regional level in Italy.